Morbidity Profile, Economic Impact, and Social Security Scheme Utilisation of Occupational Injuries in a Tertiary Care Hospital in Bangalore, Karnataka

Abstract

Introduction:

Occupational injuries pose a critical challenge amid India’s rapid industrialization. National Programme on Occupational Diseases Quadrant I reports alarming global statistics, with India contributing significantly to the burden. Injuries impose a significant financial burden on individual households, leading to substantial out-of-pocket expenditures (OOPE) causing severe financial distress for the families of the victims. This study explores the profile and economic ramifications of such injuries, emphasizing the urgent need for intervention.

Methods:

This cross-sectional mixed methods study, conducted in a tertiary care hospital in Bangalore, Karnataka, analyses data from 148 occupational injury cases over 6 months. Ethical approval was obtained, and data were collected from hospital records and direct patient inquiries. Demographics, injury characteristics, root causes, and outcomes were analyzed. The economic burden, catastrophic health expenditure, awareness, and utilization of social security schemes (SSS) were assessed.

Results:

A predominant demographic vulnerability exists among workers under 25 years old, especially in high-risk sectors. Traumatic injuries, primarily due to employee negligence, are prevalent, with extremity injuries and ocular injuries being common. While 68.9% of participants claimed access to personal protective equipment (PPE) at their work sites, only 51.4% reported actual usage of PPE. A significant financial strain was observed, with 64 out of 148 participants experiencing catastrophic health expenditure. Insurance coverage and SSS utilization are limited, indicating gaps in awareness and procedural complexities.

Discussion:

The findings underscore the need for targeted interventions, particularly in high-risk sectors and during vulnerable periods, such as postlunch hours. Bridging the gap between PPE availability and utilization is crucial. The study emphasizes the importance of collaborative efforts between regulatory bodies, employers, and workers to enhance safety measures. Furthermore, it highlights the challenges and successes in SSS utilization, suggesting the need for streamlined processes and increased awareness campaigns. Recommendations include targeted interventions, safety training, and streamlined SSS processes to address the complexities surrounding workplace incidents and improve overall occupational well-being. Continued research is crucial to refining preventive strategies and mitigating the impact of occupational injuries.

Conclusion:

This study reveals the urgent need for improved safety measures and streamlined social security schemes to mitigate the significant economic burden of occupational injuries in India.

INTRODUCTION

Amidst India’s rapid march toward industrialization and economic growth, the toll of occupational injuries reveals a pressing concern that demands both attention and action. The Employees’ State Insurance (ESI) Act, 1948, Section 2(8) defines “employment injury” as personal injuries sustained by employees due to accidents or occupational diseases that occur within the scope of their employment, regardless of whether such incidents take place within or outside the territories of India.[1] These injuries result in substantial disability and mortality among workers, exerting a profound impact on their economic well-being as well as that of their families. In addition, these incidents have a detrimental effect on work productivity, corporate profits, and the overall welfare of the community.[2]

There are approximately 100 million occupational injuries and 1 lakh fatalities each year globally.[3] In India, the situation is equally disconcerting, as it witnesses an estimated 17 million nonfatal injuries (constituting 17% of the global burden) and 45,000 fatal injuries (accounting for 45% of global fatalities) annually.[4] The significance of these statistics resonates, casting a spotlight on the considerable scope and profound implications of occupational injuries in India.

Although automation and technology replace human labor in some sectors, the average workforce still engages in labor-intensive jobs with direct machinery interaction.[5] Many unregulated industries in India pose a heightened risk of occupational injuries. Insufficient regulations and safety measures further amplify the risk.[6]

Individual households bear a substantial financial impact from injuries, causing high out-of-pocket expenditures (OOPE) and severe financial distress for victims’ families. The National Sample Survey (NSS) reports an average OOPE of INR 23,491 (USD 368.9) per injury-related hospitalization case in India.[7] This figure represents only the direct expenses and excludes the full financial impact. Concealed within the shadows are the indirect costs, such as lost productivity for victims and caregivers, adding to the economic burden.[8] WHO proposes that health expenditure should be called catastrophic whenever it is greater than or equal to 40% of the capacity to pay.[9] Some studies have defined catastrophic health expenditure (CHE) as a total health expenditure that is more than 10% of annual income.[10] Expensive health care, a limited ability to pay, and a lack of health insurance are all antecedents to catastrophic health expenditures.[11]

By analyzing the economic burden of occupational injuries, policymakers gain valuable insights for resource allocation and identifying priority areas in occupational health and safety policies. We undertook this study to evaluate the profile of occupational injuries that were presented to the Emergency Department in a tertiary care academic hospital in Bangalore, Karnataka. We also assessed the extent of direct and indirect expenses for the same along with the utilization of the social security schemes (SSS) regarding occupational injuries.[12]

METHODOLOGY

This is a cross-sectional mixed methods study, among all the documented cases of occupational injuries that occurred within 6 months in the emergency department in a tertiary care hospital in Bangalore, Karnataka.

Before commencing the study, ethical approval was obtained from the Institutional Ethics Committee. The study includes all patients aged 18 years and above, who have experienced workplace injuries regardless of whether they work in organized or unorganized industrial sectors. For this study, comprehensive data were collected from two primary sources: hospital records and direct phone inquiries with the patients. The population for our study was collected by employing universal sampling, which involved obtaining data from all patients who visited the emergency department over a 6-month period. From a total of 221 patients during this timeframe, we successfully obtained data from 148 individuals through direct phone inquiries, using a semistructured, face-validated, self-administered standard interview schedule, constituting the final sample size for our analysis. It covered various aspects related to patients’ financial and occupational circumstances and SSS awareness and utilization. CHE was calculated based on the budget share approach.[13,14] The data collected were entered into Microsoft Excel® and analyzed using SPSS version 21. Sociodemographic variables were described as frequencies and measures of central tendency. The data collected were analyzed using descriptive statistics. Means, medians, and proportions were applied.

RESULTS

A total of 148 injury patients were recruited for the study. The mean age of the participants was 30.6 ± 10.29 years, spanning an age range from 18 to 66 years with a majority of 144 being males. The number of occupational accidents is found high in the <25 years age group (40.3%). The study revealed a substantial majority, with 38 (25.6%) participants falling under the category of laborers in mining, construction, manufacturing, and transport. The mean formal education (in years) was found to be 9.12 ± 3.73 years, and work experience in the current roles exhibited a mean of 7.47 years. Scheduling patterns demonstrated that a considerable percentage, 63.5% adhered to the standard 9 am to 5 pm schedule, while 33.7% were subject to shift rotation with a mean working hours of 9.18 hours/day. The peak period for injuries was from 12 pm to 4 pm, accounting for 35.8% of cases [Table 1].

Table 1.

Sociodemographic details

Demographic characteristics	n (%)
Age (in years)
<25	60 (40.3)
26-35	51 (34.2)
36-45	24 (16.2)
46-55	9 (6.7)
>56	4 (2.6)
Gender
Male	144 (97.3)
Female	4 (2.7)
Shift Schedule
(9 am- 5 pm)	94 (63.5)
(5 pm- 12 am)	2 (1.4)
(1 am- 8 am)	2 (1.4)
Shift rotation	50 (33.7)
Part-time/Full-time Job
Full-time	145 (98)
Part-time	3 (2)
Occupational classification*
Laborers in mining, construction, manufacturing, and transport	38 (25.6)
Cleaners and helpers	18 (12.2)
Food processing, woodworking, garment, and other craft and related trade workers	17 (11.5)
Science and engineering associate professionals	14 (9.5)
Electrical and electronic trade workers	11 (7.4)
Food preparation assistants	10 (6.7)
Stationary plant and machine operators	10 (6.7)
Others	30 (20.4)
Educational Status (in formal years of education)	9.12±3.73
Experience in current work (in years)	7.47±7.5
Working hours (per day in hours)	9.18±2.39

*Participants’ occupational classifications were meticulously categorized with the International Standard Classification of Occupations (ISCO-080)

The study also delineated a division between traumatic and nontraumatic injuries. Traumatic injuries include direct mechanical like crushing/cutting injuries, falls from height, and assault, while nontraumatic include injuries due to exposure to chemicals, electricity, and heat, revealing that 133 participants encountered traumatic injuries. An in-depth examination of the root causes behind these injuries revealed that 63.5% of incidents were a result of employee negligence, with many cases attributed to lapses in caution on the part of the worker. Another contributing factor was poor working conditions (evaluated based on the telephone conversation with the subjects) accounting for 12.8% of injuries. Turning to patient outcomes, the distribution revealed that 35.8% of participants were discharged directly from the emergency department and 44.6% of individuals were admitted to the ward and subsequently discharged [Table 2]. Notably, most instances of Discharges Against Medical Advice (DAMA) were due to the absence of available bystanders to provide necessary care for the patients.

Table 2.

Characteristics of the injury

	n (%)
Type of Injury
Fall of person on same level	18 (12.2)
Fall of person on lower level	27 (18.2)
Struck against object or equipment*	11 (7.4)
Hit by objects (a moving object or equipment striking a worker)	55 (37.2)
Overexertion in lifting or lowering	1 (0.7)
Caught in object, equipment, material	20 (13.5)
RTA	1 (0.7)
Exposure to harmful substance or environment	3 (2)
Exposure or contact with extreme temperature	7 (4.7)
Electric injury	5 (3.4)
Root Cause of Injury
Worker negligence	94 (63.5)
Faulty machine or equipment	17 (11.5)
Poor working environment	19 (12.8)
Poor worker health	4 (2.7)
Break of structure	2 (1.4)
Co-worker negligence	12 (8.1)
Outcome
Discharged from Emergency department	53 (35.8)
Discharged from ward	66 (44.6)
ICU admission	9 (6.1)
DAMA	13 (8.8)
Transfer out	7 (4.7)

Classification for the type of injury was obtained from the website of the US National Safety Council.[15] *Struck against object or equipment- A worker striking against an object or equipment (including bumping into, stepping on, kicking, or being pushed or thrown onto an object.)

In terms of injury location, 106 patients sustained extremity injuries, while 44 experienced head injuries. In addition to these, there were 10 cases involving thoracic injuries, 9 cases with abdominal injuries, 8 incidents affecting the back and spine, 4 instances concerning the neck, and 4 occurrences related to the pelvis and genitals. Thirteen patients experienced ocular injuries, and eleven participants sustained burns [Figure 1]. For burn injuries, the mean burned body surface area was calculated at 19.77%, with a standard deviation of 14.25. A total of 15 patients (10%) had experienced amputations during the incident.

Figure 1.

Distribution of injury sites

The most common cause for hospital admission was being hit by objects, affecting 25 individuals. The longest hospital stay, lasting 47 days, was due to an electric injury. The mean hospital stay for patients with electric injuries was 29.25 ± 14.31 days.

In terms of work engagement, 3 participants were noted to be involved in part time employment.

A noteworthy observation was that 15 participants reported a history of workplace injuries. A majority (68.9%) of participants reported access to personal protective equipment (PPE) at their work sites. However, actual usage of PPE was reported by 51.4% of the total participants.

The distribution of costs for various types of injuries in INR is given in Table 3. Regarding their wages during the period of absence from work, 41.2% of participants were fully paid, 47.3% received no pay, and 11.5% were partially paid. Out of the 148 patients, 64 (43.2%) had experienced CHE. CHE was notably higher among individuals lacking insurance or any social security schemes, as indicated by Pearson’s Chi-square value of 6.005 and a corresponding P value of 0.016, highlighting statistical significance.

Table 3.

Distribution of cost of injury

Type of Injury[15]	Direct Cost (Median, IQR) INR	Indirect Cost (Median, IQR) INR
Fall of person on the same level	12500 (7025-48000)	4332.5 (0-17475)
Fall of person to lower level	58000 (18720-156930)	25200 (0-43800)
Struck against object	9600 (5500-42002)	0 (0-40000)
Hit by objects	25000 (4300-44000)	2100 (0-25000)
Overexertion in lifting or lowering	3100 (3100-3100)	0
Caught in object, equipment/material	67500 (28702-109950)	1000 (0-41850)
RTA	47000 (47000-47000)	45000 (45000-45000)
Exposure to harmful substances or the environment	24000 (1450-24000)	7000 (0-7000)
Exposure or contact with extreme temperature	55000 (2300-190000)	2100 (0-32800)
Electric injury	240000 (53250-657500)	16000 (0-114600)

Direct expenses=Medical expenses and Nonmedical expenses such as transport, food, accommodation, visitors food and accommodation, vehicle parking charge, etc. Indirect expense=loss of wage for the patient, loss of wage for the caregiver

Insurance coverage and social security schemes

Among participants, 36.5% benefitted from company credit coverage, 18.9% from company insurance, and 7.4% were covered by the Employees’ State Insurance (ESI) scheme. Among the scheme beneficiaries, 78.9% received full coverage of their medical bills.

Moreover, the study delved into participants’ cognizance, utilization, and experiences with SSS. Notably, 39% had heard of such schemes, often through friends and colleagues (25.8%) and other channels. Among beneficiaries of these schemes, 45% had adequate awareness of scheme benefits, while 7.5% possessed a comprehensive understanding of the claims process. Interestingly, among the patients who had claimed such schemes in this event or in the past (18 participants), a substantial 94.4% expressed satisfaction with the benefits garnered from these schemes.

Participants encountered several challenges when claiming benefits from SSS. Approximately 50% found the process time-consuming, 16.6% were unfamiliar with the procedures, and another 16.6% had difficulty with the paperwork. Importantly, 44.4% of participants reported no issues, likely due to their familiarity with the system or effective support (note that percentages do not sum to 100% due to multiple responses from participants). The intricacy of claiming benefits from SSS was evident, with 50% finding the process complex. It was seen that 97.5% expressed a strong inclination to prefer hospitals that accept these schemes.

Participant opinions and suggestions about the insurance and SSS were diverse. Many voiced the need for simplified procedures and increased awareness campaigns. Some suggested better coordination between hospitals and scheme authorities to expedite the claiming process. Participants emphasized the significance of transparent communication about benefits and procedural steps. Considering challenges faced during the entire event and treatment, participants emphasized job-related concerns (20%), financial strains (71%), and prolonged pain (26%) as prominent issues.

DISCUSSION

Our study revealed a concerning trend indicating a disproportionate impact of occupational injuries on our workforce, especially those under 25 years old, possibly due to their limited experience in hazardous work environments. This age profile aligns with the majority of cases involving laborers in mining, construction, manufacturing, and transport, along with cleaners and helpers, constituting 25.6% and 12.2% of cases, respectively, indicating a preference for a younger population. Sayhan MB et al.[16] reported analogous findings in a study conducted on occupational injuries in a Turkish hospital’s emergency department. In addition, our observations resonate with the outcomes of studies conducted by Regina D et al.[5] at CMC Vellore and Abdolrasoul Rahmani et al.[17] in an electricity distribution company in Iran.

The study distinguished between traumatic and nontraumatic injuries, with 90.2% of participants experiencing traumatic incidents, mostly due to object impacts and falls. Out of the nontraumatic injuries (10%), the majority were due to exposure or contact with extreme temperatures. In both traumatic and nontraumatic injuries, the majority was due to negligence on the part of the employee and most injuries are at the extremities. This correlates with another study conducted by Rahmani A et al.[17] The dominant cause, worker negligence underscores the imperative for rigorous training, emphasizing safety protocols to instill a culture of safety.

While 68.9% had access to PPE, only 51.4% used them, indicating a gap between availability and utilization. Bridging this gap through robust safety training can significantly reduce workplace accidents, emphasizing the importance of collaborative efforts between regulatory bodies and employers.

The study revealed a substantial concentration of injuries among employees working the standard shift from 9 am to 5 pm, constituting 63.5% of the total cases. Mixed shift workers accounted for 33.7%. Our study identified a notable increase in injuries between 12 pm and 4 pm, constituting 35.8% of cases, coinciding with the postlunch period probably associated with postprandial somnolence. This midday decline in alertness may contribute to lapses in concentration, potentially leading to workplace accidents. Our observations, consistent with the findings of Ganesh Kumar et al.,[18] which revealed that a majority (59%) of individuals in our study worked fewer than 8 hours per day. This similarity prompts further investigation into the implications of both shorter work hours and the standard schedule on occupational well-being and broader productivity.

Even though statistically insignificant, it is noteworthy that among patients who underwent pretraining, only 28% experienced severe injuries, compared with 42% in patients who did not receive pretraining. The length of hospital stay can be taken as a proxy measure of the severity of injuries according to a study by Craig D. Newgard et al.[19]

CHE was observed in 43.2%, highlighting a significant financial burden on a substantial portion of the study population. Our study showed a higher odds of incidence of CHE among households who lacked insurance or any social security schemes. This shows that health insurance and other health financing protection mechanisms have proven effective in diminishing the number of households being pushed to experience CHE. The share of OOPE in Total Health Expenditure (THE) in India reduced from 62.6% to 47.1%, indicating progress toward financial protection. In comparison, across the EU countries, it is approximately 15% and the world average is 16.36%, highlighting the disparity in healthcare financing between India, the EU, and the rest of the world.[20,21]

In contrast to the findings of this study, previous research conducted by Rohan Sachdev et al.[12] reported a higher awareness percentage of 84% among participants regarding SSS. However, despite the lower proportion of awareness percentage in our study (39%), it is noteworthy that among the beneficiaries, 45% displayed adequate awareness of scheme benefits, and a significant 94.4% of those who had claimed benefits expressed satisfaction with the schemes. These results imply that while overall awareness might be lower, efforts to inform and educate beneficiaries about the benefits and claims process have been relatively successful.

CONCLUSION

Our study highlights a notable number of occupational injuries predominantly affecting young male workers, notably those categorized as laborers in high-risk sectors such as mining, construction, manufacturing, and transport. Most traumatic injuries were linked to employee negligence, with extremity and ocular injuries being notably higher. The analysis highlighted a significant financial burden, leading to CHE, underscoring the challenges and successes in SSS utilization. To address these concerns, we recommend targeted awareness campaigns to enhance safety measures and the utility of SSS. The multifaceted nature of occupational injuries warrants continued research to refine preventive strategies and address the complexities surrounding workplace incidents.

Strengths of the study

• Mixed Methods Approach: Combining quantitative and qualitative data provides a comprehensive understanding of occupational injuries and their impact.

• Comprehensive Economic Analysis: Evaluating both direct and indirect costs highlights the full financial burden and underscores the need for effective health financing.

• Assessment of Social Security Schemes: Analyzing awareness, utilization, and satisfaction offers valuable insights for improving these programs.

• Standardized Classifications: Using the International Standard Classification of Occupations (ISCO-08) ensures consistency and comparability with other studies.

Limitations

• Limited Sample Size and Scope: The small sample size from a single hospital may not represent the broader population.

• Underreported Non-Traumatic Injuries: Focusing on traumatic injuries may overlook the full range of occupational health issues, including non-traumatic injuries.

• Recall bias: During the qualitative part of the study, participants were asked to recall past experiences related to occupational injuries and SSS claims.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.